Heavy workloads can interfere with the formation of collaborative relationships. Collaboration requires that staff have the time to participate in such activities as interdisciplinary team meetings (Baggs and Schmitt, 1997). Illustrating this point, additional staff resources and reduced caseload were identified as two of several components of success in a randomized controlled trial of collocating and integrating medical care with mental health care (Druss et al., 2001). When staff are overwhelmed with caregiving responsibilities, they may not take the time to collaborate. Yet while unilateral decision making is easier in the short run, collaborative relationships are viewed as saving time in the long run (Baggs and Schmitt, 1997).

The committee also calls attention to the Chronic Care Model, used to improve the health care of individuals with chronic illnesses in primary care settings. This model has six components: (1) providing chronic illness self-management support to patients and their families (see Chapter 3); (2) redesigning care delivery structures and operations; (3) linking patients and their care with community resources to support their management of their illness (described above); (4) providing decision support to clinicians (see Chapter 4); (5) using computerized clinical information systems to support compliance with treatment protocols and monitor patient health indicators (see Chapter 6); and (6) aligning the health care organization’s (or provider’s) structures, goals, and values to support chronic care (discussed below) (Bodenheimer et al., 2002). The Chronic Care Model has been applied successfully to the treatment of a wide variety of general chronic illnesses, such as diabetes, asthma, and heart failure (The National Coalition on Health Care and The Institute for Healthcare Improvement, 2002), as well as to common mental illnesses such as depression (Badamgarev et al., 2003), and has been theorized to have the potential for improving the quality of care for persons with other M/SU illnesses (Watkins et al., 2003).

The Chronic Care Model also emphasizes the use of certain organizational structures and processes, including interdisciplinary practices in which a clear division of the roles and responsibilities of the various team members fosters their collaboration. Instituting such arrangements may necessitate new roles and divisions of labor among clinicians with differing training and expertise. In the Chronic Care Model, for example, physician team members are often responsible for the treatment of patients with acute conditions, intervene in stubbornly difficult chronic care problems, and train other team members. Nonphysician personnel support patients in the self-management of their illnesses and arrange for routine periodic health monitoring and follow-up. Providing chronic care consistent with this model requires support from health care organizations, health plans, purchasers, insurers, and other providers. Elements of the Chronic Care Model have been implemented in a variety of care settings, including private general medical practices, integrated delivery systems, and a community health



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